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Football is a rough sport – people get tackled, slip and fall, hit their heads and other body parts and experience severe dehydration … and that’s just the fans! While sports medicine is a field in and of itself, emergency physicians have emerged as critical caregivers for sporting events and are now instrumental in treating injuries and illnesses on and off the gridiron.

On the player side, the injuries and illnesses tend to be high-profile and often much more serious – especially in the National Football League (NFL). Professional players are essentially paid to hit each other, tackle each other, run themselves ragged and physically exert themselves in all sorts of unimaginable ways. EmCare Executive Vice President Thom Mayer, M.D., also serves as the medical director for the NFL Players Association (NFLPA), which is commonly referred to as the NFL’s “players’ union.” Dr. Mayer first became involved with the NFLPA as a personal favor.

“Gene Upshaw, who was previously the executive director of the NFLPA and has unfortunately passed away, was my best friend,” said Dr. Mayer. “I had been advising him on player safety issues kind of just as a friend. And on August 1 of 2001, Korey Stringer, a tackle for the Minnesota Vikings, died of heat stroke. He should not have ever been exposed to that and certainly shouldn’t have died from it. Gene asked me to get involved as the medical director for the players’ association. So I have done that the past 12 years.”

In his role as NFLPA medical director, Dr. Mayer is the sole medical advisor for health and safety issues to the 1,500-1,800 active players as well as the players who have ongoing or recurring conditions such as concussions and cardiovascular disease. His duties with the NFLPA include overseeing the care provided by the team orthopedists and the primary care sports medicine physicians.

“We’ve added a number of different things over the course of the years, including the requirement that there be a rapid sequence intubation (or RSI) physician on the sideline of every game,” said Dr. Mayer. “There are now two concussion experts who are neurologists, neurosurgeons or emergency physicians required to be at each game. So indirectly there have been a number of EmCare physicians for the [Dallas] Cowboys, for example, and other teams that are involved with providing care to NFL players - either through their work as on-site physicians or as these concussion experts on the sidelines.”

Many physicians paid close attention to the concussion lawsuit players brought against the NFL, which was settled over the summer of 2013 for $765 million. Neither the NFLPA nor Dr. Mayer were directly involved in that litigation. Like the NFLPA, Dr. Mayer doesn’t comment on the settlement, instead focusing on the current cases. Being medical director of the players union is a demanding, daily commitment in and of itself during the football season.

“Once the season’s on, it’s very much a day-to-day involvement. For example, a player that was injured recently during an [Oakland] Raiders game – I’ve been on the phone and conference calls pretty much all morning long regarding his care. Why his concussion wasn’t diagnosed at the time of his injury – that sort of thing. His injury wasn’t picked up until several plays later. During the season, I’ve got pretty much constant involvement with all the NFL injuries. I get video downloads of all NFL plays where injuries occurred and I review those and go over them with our staff and, if necessary, the team physicians as well.”

Whether he is involved with player cases over the phone or in person, it’s clear Dr. Mayer has great admiration for the NFL players.

“I would call them warriors, except I have a son that’s a marine infantry officer and he’s a real warrior,” said Dr. Mayer. “But these players are top-tier athletes and they’re tough. And they’re good men … fun to be around … they’re bright, they’re intelligent, they’re good family men, they have great values and it’s just a pleasure to be involved with them and make sure that they get the highest level of care possible.”

As for name-dropping, which Dr. Mayer could certainly do, he seems to avoid it.

“I have a lot of cool, name-dropping stories, but none that I’m going to share!” laughed Dr. Mayer when prompted for a celebrity anecdote. “I’ll just say they’re all first-rate people.”

Dr. Mayer’s most memorable event as NFLPA medical director doesn’t involve a big-name athlete, but a memorable event for many football fans: The power outage at Superbowl XLVII, at the Mercedes-Benz Superdome in New Orleans.

“I was there with our sons,” Dr. Mayer recalled, “but one of them didn’t happen to be in the seats with us at the time. Then the lights go out, and my wife starts wondering if he has anything to do with this power outage! I think some people thought maybe the 49ers did, because they were kind of reeling at that point, but at any rate it was an unusual occurrence and I will say that the Superdome got really steamy during that 45 minutes or so when the air conditioning was off. Everything worked out fine – although I’m not sure the 49ers would agree!” (The San Francisco 49ers lost that game to the Baltimore Ravens by a score of 34-31.)

Although Dr. Mayer’s role as medical director with the NFLPA affords him trips to the Superbowl and friendships with famous athletes, the ultimate satisfaction for him has nothing to do with his high-profile patients.

“I like the same thing that every physician likes – being able to help my patients,” he said. “Being able to make a difference in their lives. That’s why we all went into medicine and healthcare in the first place. So it’s a real joy to help take care of them. They’re always very grateful. But it’s not the gratitude - it’s just the feeling that I’m doing things that help change their lives and help make sure that when they’re older and looking across the table at their wives and kids, that they’re all getting the best healthcare they can get.”

As medical director for the NFLPA, Dr. Mayer has also gained a lot of takeaways that help him in his role with EmCare. As an EmCare executive vice president he is widely regarded as one of the company’s leading experts on hospital organization and patient flow. One NFL anecdote Dr. Mayer regularly shares during his speaking engagements involves Superbowl XLV in 2011, which pitted the Green Bay Packers against the Pittsburgh Steelers.

“I’m watching the Packers warm up before the Superbowl, and I notice they have a whole bunch of guys that aren’t in their uniforms - they’re in shorts and T-shirts,” Dr. Mayer recalled. “It turns out at that time they had 16 players on injured reserve. And yet Aaron Rogers didn’t go in the huddle and complain about who wasn’t there, he didn’t give up. He made do with who he had available. [The Packers won that game 31-25]. I think that’s a good lesson for a medical director and all emergency physicians - to be able to say, some days we’re going to work short-handed, we’re not going to have the best available talent or even have all of the equipment we want or normally have - but we’ve got to make do and call different plays, to best utilize the people we do have and not be concerned about who or what isn’t available.”

That notion of doing the best with what’s there is likely very important for emergency physicians like David Mendelson, M.D., who practices medicine in stadiums across the country. In addition to being an executive vice president with EmCare’s South Division, Dr. Mendelson oversees physician staffing for AT&T Stadium in Arlington, Tex. Better known as the home of the Dallas Cowboys, the $1.5 billion stadium was built to be state of the art in every way – right down to the eight bed emergency department that serves as the main first aid center. But even with a first aid center that’s capable of running like a small E.D., being responsible for 100,000 passionate fans on any given Sunday can be a daunting task.

When the Cowboys organization built the new stadium in 2011, they decided that they wanted to set up a program where a physician is provided along with the regular coterie of paramedics (EmCare’s sister EMS company, AMR, holds that contract with AT&T Stadium). At AT&T Stadium, as well as a lot of large stadiums across the country, the first aid physician also acts in concert with sports teams’ physicians and trainers. To use a sports metaphor, the primary first-aid physician also acts as a “backup player” – one more Board certified, residency trained physician accessible to the field in case catastrophe strikes a player or other member of the team.

“Over the last 20 years or so, emergency physicians have kind of come forward as the best kind of physician to staff these big events where people have a tendency to fall down, drink too much, get cut or even just get a headache,” said Dr. Mendelson. “We have some first-rate first aid stations all over the stadium. But the main first aid station is basically just like an eight-bed emergency department. We pretty much can do anything. We can stabilize people, we can resuscitate people. We can put in IVs, intubate them if we need to, if somebody has a cardiac arrest we can take care of them. And of course we have to be able to take care of them right where they are, at field level, to be able to transport them to local hospitals.”

Dr. Mendelson also says that stadium events often attract the best possible medical staff.

“For all of the events except for the Superbowl, which was here [at AT&T Stadium, then known as Cowboys Stadium] a couple of years ago, all of the football stadiums throughout the country are staffed by paramedics,” Dr. Mendelson said of the staff makeup. “And these are really highly-trained paramedics, the best in the Arlington area. And then the main first aid station is staffed with a physician. And the paramedics and medical-based command sort of make the call if somebody’s sick, whether to get them down to the main first aid station where the physician is, or perhaps take them directly to the hospital. We’ve got established protocols for all of that.”

Established protocols and access to appropriate care are particularly important when tens of thousands of rabid fans come together. A particularly memorable event for Dr. Mendelson came not from an American football game, but the other kind of football.

“I was attending a soccer game that was between Mexico and Panama,” he said. “There were so many people who had been there all day tailgating and drinking. We had more people than we could care for due to wide-spread dehydration and people passing out – there were multiple trips to the hospital. But also, and this is what was amazing to me, there were probably 50 people arrested and lined up down the walkways and around the corner to where the main first aid station was.”

When 100,000 people pay big money to cram themselves shoulder-to-shoulder into a stadium to watch a high-energy, high-emotion game, injuries can (and usually do) happen. That passionate fan base typically leads to the greatest challenge for Dr. Mendelson and other physicians practicing “event medicine." While, generally speaking, no patient ever really wants to go to the E.D., event-goers are even more reluctant patients.

“People have spent a lot of money to be there at the stadium,” said Dr. Mendelson. “And if they come for first aid they want us to help them feel better right away so they can get back to the event. The fact is, the best thing for them is usually to go home and rest or maybe to get an IV and take an ambulance to the emergency department of a local hospital – but that’s not what they want to do. And they resist medical care more than anyone I’ve treated. And they have the right, quite frankly, to decline care. At nearly every event I’ve worked, there are patients who will sign a form saying that they’re refusing treatment or refusing to stay or going against medical advice because they just want to get back to their seat. So understanding that we want to please the patient, get them back to their event, but also do the right thing for them - that’s the balance that physicians have to learn with event medicine.”

As for the cases that Dr. Mendelson treats most often, he mentions those relating to alcohol.

“There are a lot of drunk people!” he laughed. “But event medicine really is a lot of fun. Whether you’re a paramedic or an emergency physician, if you haven’t tried it you ought to try it no matter what city you’re in. It can be a great challenge, but it’s a lot of fun to be around the people who promote these events and see how much work goes on behind the scenes – from a media standpoint, from a production standpoint, even just watching the teams in action off of the field. Cheerleaders, mascots – it’s just a fun atmosphere in which to practice medicine.”